Center Stage Youth Theater Registration Form

Student's Information
Last Name*
First Name*
Middle Name*
Gender*

MaleFemale
Address*
City*
State*
Zip*
Birth Date*

MonthDayYear
Current Grade in school*
Please select a date or dates*

October 21st 3:30-5 p.m.November 4th 3:30-5 p.m.November 18th 3:30-5 p.m.Shadow Puppet Workshop
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Work Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Parent /Legal Guardian 2
Relation 2
Work Phone 2

Area CodePhone Number
Cell Phone 2

Area CodePhone Number
Home Phone*

Area CodePhone Number
Emergency Contact Info
Emergency Contact Name(if parent or guardian is not available)*
Emergency Number*

Area CodePhone Number
Emergency Number #2*

Area CodePhone Number
Cabin Buddy

List first and second choice, not all requests are quaranteed.
Cabin Buddy #1
Cabin Buddy #2
Email Confirmation
Parents Email (confirmation will be sent by email, if left blank it will be mailed)*
Camper's Email
Other Information
How did you hear about Camp FunQuest?
First Time Camper? (If yes, subtract $25 from camper fee)*

YesNo
Health Information
Are immunizations up to date?*

YesNo
Date of last tetanus shot
Any activity the camper should be restricted from?
Any physical, mental or other condition that would require special attention?
List all medications, both prescribed and over the counter.
List any allergies (ex: bees,peanuts, dairy)
Any dietary needs that we should know about?
Student Photo Release
I agree that photos of my child can be taken and used for social media purposes*

YesNo
Payment Information
Method of payment

VenmoCheckCash
- Be certain to enter your email address correctly on the registration form to receive confirmation via email within 2 weeks
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named student, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named student by authorized personnel. CenterStage carries secondary insurance. I understand that the above named student will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend this workshop(s) and participate in all activites.
Electronic signature, please initials*
Should be Empty:

Student's Information

Parent or Legal Guardian Information

Emergency Contact Info

Cabin Buddy

Email Confirmation

Other Information

Health Information

Student Photo Release

Payment Information